90 SUMMER ST - BUILDING INSPECTION f�MWSTSEiRWW rND APPROVED BY 774E
ASP==PWR TD A PEM f RMG GRANTED
2 CITY OF SALEM
No. �\ ) ^ —\ v� \ Date
Wad
Zoning DOW
la PMPwly Looabd In Location of
the HWa tc Dktod? Yes No— aaildins 910
Is Propwty Located in
Ue Caroervatlon Ann? Ym No Permit to: —
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Remof, Install Siding, Construct Dedc, Shed, Pool,
Repair/Replace, Other: uE' Po R C h/
PLEASE FILL OUT LEGIBLY i COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build accorddsig.to the following
specifications:
Owners Name ��6ylj Z)De'j"IL
Address & Phone ?'q Slk-, S ( l / 7
Architect's Name
Address & Phone ( )
b�
MeehanName1 Nr
ics
Address & Phone 90 ( 7,F) 74-/ 4 7�,P
Who Is the Purpose ct buUdNq?
MdWW of tarldirtg? G�vt'q) n a dweNng,for how many temaea? Z
WN 4+k"cordorm to law? Aeeedos?
Eetimded cod 1 ODo CRY LIMM a slam Lloerea 0 C 06'7 3 Sv
as.. lapro.went - �,
Lie. I►
ature of Applicant
41 �I ED UNDER THE PENALTY-
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT T0:
.t
APPLICATION FOR
PERMT TO
LOCATION
PERMIT GRANTED
AP �D
INSPECTOR CW BUILDINGS
. COA►M4AWY6ifA 4 !//amachu ifil
booUyy/..1;.�.-Sfawl
,.n�1 canofad &ego*. //JeaaeI.A 02111
Cosaswaan
Workers' Compenadow Imurann Affldayit
1, �o t li'N� •
- • whb.a principal place o/btnivaa act
%0 lti1/}ze fin,✓ -✓>- fi�c� 9- p`/, 7a
do hereby'cerWy under:be pales and penil" of parley, clop
() Ia an employer providlni workers, cornpeanden covepde for eery emplay4m woekbg M
Insurance Compaq► Follcy Number
1 am a sole propnfetw and have no one werkiK fear me it any capedp.
() 1 am a sole proprleame general concramor or homeowner (did one) and have hied tit
contracton lirsed below who-have thi folkawk* workers' comp mansion poldw
Conwaetnr insuranis Company/Polley Nom6w
Contraetor Insurance Company/Po Numbw
Contractor Insurance Compaq/Policy Number
() 1 am a homeowner performing all the work myself.
•I easervA ,ew a cm of db auwraaw we be km.areee w ew Olko A M.e$ae of dw M for cvvwane.aalkaeae me on ilea a man
CO WOW a icwwro.nes Socda 21A of MGL 112 cas kw Mow WIPaade of w6wir w oaode cenwint of a fie of n=41 500.00 anale.eae
ream':.re.onwir a vs a d.i aMW&in / OF W ORK ORM see a bw of 1 Iff0,00 s an ariwe.n _
Signed this • 0 of77—
�' n
:icerseeiFc cse building Department
JCensin( Ecarie
Seiectmens Office
^ealth DeFarmer,�
PUOUC PROPERTY DEPARTMENT
120 WASHINGTON STREaT, 3RD FLOOR
SALEM,MA 01970
TEL(979)74"59$ MIT.360
FAX (07e) 740.9e4S
STANLEY J. (JSOVN:Z, JR.
MAYOR
DISPOSAL OF DEBIM AFFIDAVIT
In accordance with The provisions of MGL c 40,S34,I acknowledge that as a condition
Of Building Permit 0 .aII debris resulting from to cmsMwtionscp Y
goveraed by thin Building Permit shag be disposed of in a propaly licensed AOH&was0e
disposal facility,as defined by MGL c 1M S1SOA.
dispoAa of at: /�//��Y1Ot� (±
The debris wr71 be
Location ofFacr'lity
IS Permit Applicant Dame
Y complete die Wowing
(PLSE EA PRINT CLEARLY) »> on
Name ofPcUnO plicaat
�l F L'wN /A✓/)
Firm Name,if any
7f —trial �J j � a., /"P� dl q 70
Address,City dt State
The above Statute requires that debris from the demolition.renovation.rehab or otba
aitmzdOu Of boik ing Or sbuc(ue be disposed in a properly-licensed Sokid-waate disposal
facility As defined by MGL cM S 1 SOA, and the building permits or licenses
are to
indicate the location of the 'filcrhty.